o DELTA DENTAL" Administered by Delta Dental Insurance Company DeltaCare USA - provided by Delta Dental ofcalifornia

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1 DeltaCare USA - provided by Delta Dental ofcalifornia Welcome to DeltaCare USA - quality, convenience, predictable costs Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general dentists. To find the most current listing of DeltaCare USA dental offices you can: DeltaCare USA (administered by Delta Dental Insurance Company) provides you and your family with quality dental benefits at an affordable cost. The DeltaCare USA program is designed to encourage you and your family to visit the dentist regularly to maintain your dental health. When you enroll, you select a contract dentist to provide services. The DeltaCare USA network consists of private practice dental facilities that have been carefully screened for quality. Enroll in DeltaCare USA and you'll enjoy these features: Visit our website at deltadentalins.com/ enrollees. Under Find a dentist, select DeltaCare USA as your network. Or call Customer Service at for help in finding a DeltaCare USA dentist. Quality Extensive benefits for you and your family No restrictions on pre-existing conditions, except for work in progress Large, stable network of dentists, so you can enjoy a long-term relationship with your dentist Convenience No claim forms to complete Easy access to specialty care Expanded business hours for toll-free customer service, from 5 a.m. to 6 p.m., Pacific time Predictable costs No deductibles Out-of-pocket costs are clearly defined Out-of-area dental emergency coverage up to $100 per emergency No annual or lifetime dollar maximums o DELTA DENTAL" Administered by Delta Dental Insurance Company You id SCCA(STD)

2 Highlights of your DeltaCare USA Program Eligibility for you and your family What if I have questions about my DeltaCare USA Program? If you meet your group's eligibility requirements for dental coverage, you can enroll in the DeltaCare USA program. You may also enroll eligible dependents. Contact your benefits administrator if you have any questions. Easy enrollment Simply complete the enrollment process as directed by your benefits administrator. Be sure to indicate a dentist (from the list of contract dental facilities) for both yourself and your eligible dependents. Include the name of your group. How your DeltaCare USA program works Your selected contract dentist will take care of your dental care needs. If you require treatment from a specialist, your contract dentist will handle the referral for you. After you have enrolled, you will receive a Delta Dental membership packet that includes an identification card and an Evidence of Coverage booklet that fully describes the benefits of your dental program. Also included in this packet are the name, address and phone number of your contract dentist. Simply call the dental facility to make an appointment. Under the DeltaCare USA program, many services are covered at no cost, while others have copayments (amount you pay your contract dentist) for certain benefits. See the "Description of Benefits and Copayments" for a list of your benefits. Please note: Dental services that are not performed by your selected contract dentist, or are not covered under provisions for emergency care below, must be preauthorized by Delta Dental to be covered by your DeltaCare USA program. Provisions for emergency care Under your DeltaCare USA program, you and your eligible dependents are covered for out-of-network dental emergencies. Your program pays up to $100 for out-of-network emergency dental expenses per emergency for each enrollee. My dentist is a Delta Dental dentist but is not on the list of DeltaCare USA dentists. Can I still receive treatment from this dentist? You must receive treatment from your selected DeltaCare USA contract dentist. Please note that Delta Dental dentists are not necessarily DeltaCare USA dentists. With more than 3,800 general and specialist dentists, the DeltaCare USA network is one of the largest dental networks in California. Do my family members receive treatment from the same DeltaCare USA contract dentist? You and your eligible dependents may receive care from the same contract dentist, or if you prefer, you may collectively select up to a maximum of three individual contract dental facilities. Can I change my contract dentist? You may change contract dentists by notifying us either by phone or in writing, or by visiting our website (deltadentalins.com). If you contact us by the 21 st of the month, the change will become effective the first of the following month. Can I have my teeth whitened under the DeltaCare USA program? External bleaching is a benefit under your program. See the "Description of Benefits and Copayments" and talk to your contract dentist about your options.

3 Highlights of your DeltaCare USA Program Does my DeltaCare USA program cover tooth-colored fillings and crowns? Porcelain and other tooth-colored materials are included as a benefit under your program. The copayment shows you what your out of pocket cost will be. How long does it take to get an appointment with a DeltaCare USA dentist? Two to four weeks is a reasonable amount of time to wait for a routine, non-urgent appointment. If you require a specific time, you may have to wait longer. Most DeltaCare USA dentists are in private group practices, which means greater appointment availability and extended office hours. Are pre-existing dental conditions and work in progress covered? Treatment for pre-existing conditions, such as extracted teeth, is covered under the DeltaCare USA program. However, benefits are not provided for any dental treatment started before joining the program (that is, work in progress, such as preparations for crowns, root canals and impressions for dentures). Orthodontic treatment in progress may be covered for new DeltaCare USA enrollees. See the "Limitations and Exclusions of Benefits." How does the DeltaCare USA program encourage preventive care? Your DeltaCare USA program is designed to encourage regular visits to the dentist by having no copayments (fees you pay to the contract dentist) on most diagnostic and preventive benefits. See the enclosed "Description of Benefits and Copayments." Does my DeltaCare USA program cover specialists' services? Your contract dentist will coordinate your specialty care needs for oral surgery, endodontics, periodontics or pediatric dentistry with an approved contract specialist. If there is no contract specialist within your service area, a referral to an out-of-network specialist will be authorized at no extra cost, other than the applicable copayment. If you or your dependent is assigned to a dental school clinic for specialty services, those services may be provided by a dentist, a dental student, a clinician or a dental instructor. What if I have questions about my DeltaCare USA program? Call Delta Dental Customer Service at We have multilingual representatives available from 5 a.m. to 6 p.m. Pacific time, Monday through Friday. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals. Our Customer Service representatives have worked in dental facilities and can answer benefits questions, as well as arrange facility transfers and urgent care referrals.

4 SCHEDULE A Description of Benefits and Copayments The Benefits shown below are performed as deemed appropriate by the attending Contract Oentist subject to the limitations and exclusions ofthe Program. Please refer to Schedule B for further clarification of Benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of Benefits under the DeltaCare USA Program and is not to be interpreted as CDT-2016 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. CODE DESCRIPTION ENROLLEE PAYS D0100-D0999 I. DIAGNOSTIC Periodic oral evaluation - established patient No Cost Limited oral evaluation - problem focused No Cost Oral evaluation for a patient under three years of age and counseling with primary caregiver No Cost Comprehensive oral evaluation - new or established patient No Cost Oetailed and extensive oral evaluation - problem focused, by report No Cost Re-evaluation - limited, problem focused (established patient; not post-operative visit) No Cost Re-evaluation - post-operative office visit $ Comprehensive periodontal evaluation - new or established patient No Cost Screening of a patient No Cost Assessment of a patient No Cost Intraoral - complete series of radiographic images - limited to 1 series every 24 months No Cost Intraoral - periapical first radiographic image No Cost Intraoral - periapical each additional radiographic image No Cost Intraoral - occlusal radiographic image No Cost Extraoral - 20 projection radiographic image created using a stationary radiation source, and detector No Cost Extraoral posterior dental radiographic image No Cost Bitewing - single radiographic image No Cost Bitewings - two radiographic images No Cost Bitewings three radiographic images No Cost Bitewings - four radiographic images - limited to 1 series every 6 months No Cost Vertical bitewings - 7 to 8 radiographic images No Cost Panoramic radiographic image No Cost Collection of microorganisms for culture and sensitivity No Cost Caries susceptibility tests No Cost Pulp vitality tests No Cost Oiagnostic casts No Cost Accession of tissue, gross examination, preparation and transmission of written report No Cost Accession of tissue, gross and microscopic examination, preparation and transmission of written report No Cost Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report No Cost Caries risk assessment and documentation, with a finding of low risk -limited to children age 3 to 19, 1 every 3 years... No Cost Caries risk assessment and documentation, with a finding of moderate risk -limited to children age 3 to 19, 1 every 3 years No Cost Caries risk assessment and documentation, with a finding of high risk -limited to children age 3 to 19, 1 every 3 years... No Cost Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services) $5.00 D1000-D1999 II. PREVENTIVE Prophylaxis cleaning - adult - 1 per 6 month period... $ Additional prophylaxis cleaning - adult (within the 6 month period) $ Prophylaxis cleaning - child - 1 per 6 month period... $ Additional prophylaxis cleaning - child (within the 6 month period) $ Topical application of fluoride varnish - child to age 19; or per 6 month period No Cost

5 01208 Topical application of fluoride - excluding varnish - child to age 19; or per 6 month period No Cost Nutritional counseling for control of dental disease No Cost Oral hygiene instructions No Cost Sealant - per tooth - limited to permanent molars through age 15 $ Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - limited to permanent molars through age 15 $ Sealant repair - per tooth -limited to permanent molars through age 15 $ Interim caries arresting medicament application - child to age 19; 1 per 6 month period No Cost Space maintainer - fixed - unilateral $ Space maintainer - fixed - bilateral $ Space maintainer - removable - unilateral $ Space maintainer - removable - bilateral $ Re-cement or re-bond space maintainer... $ Removal of fixed space maintainer $ III. RESTORATIVE - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $ per crown, beyond the 6th unit. - Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old Amalgam - one surface, primary or permanent $ Amalgam - two surfaces, primary or permanent $ Amalgam - three surfaces, primary or permanent... $ Amalgam - four or more surfaces, primary or permanent $ Resin-based composite - one surface, anterior $ Resin-based composite - two surfaces, anterior... $ Resin-based composite - three surfaces, anterior $ Resin-based composite - four or more surfaces or involving incisal angle (anterior) $ Resin-based composite crown, anterior $ Resin-based composite - one surface, posterior $ Resin-based composite - two surfaces, posterior... $ Resin-based composite - three surfaces, posterior $ Resin-based composite - four or more surfaces, posterior... $ Inlay - metallic - one surface $ Inlay - metallic - two surfaces $ Inlay - metallic - three or more surfaces $ Onlay - metallic - two surfaces $ Onlay - metallic - three surfaces $ Onlay - metallic - four or more surfaces $ Inlay - porcelain/ceramic - one surface $ Inlay - porcelain/ceramic - two surfaces $ Inlay - porcelain/ceramic - three or more surfaces $ Onlay - porcelain/ceramic - two surfaces $ Onlay - porcelain/ceramic - three surfaces $ Onlay - porcelain/ceramic - four or more surfaces $ Inlay - resin-based composite - one surface $ Inlay - resin-based composite - two surfaces $ Inlay - resin-based composite - three or more surfaces $ Onlay - resin-based composite - two surfaces $ Onlay - resin-based composite - three surfaces $ Onlay - resin-based composite - four or more surfaces $ Crown - resin-based composite (indirect) $ Crown - % resin-based composite (indirect) $ Crown - resin with high noble metal $ Crown - resin with predominantly base metal $ Crown - resin with noble metal $ Crown - porcelain/ceramic substrate $ Crown - porcelain fused to high noble metal $395.00

6 02751 Crown - porcelain fused to predominantly base metal $ Crown - porcelain fused to noble metal $ Crown - % cast high noble metal $ Crown - % cast predominantly base metal $ Crown - % cast noble metal $ Crown - % porcelain/ceramic $ Crown - full cast high noble metal $ Crown - full cast predominantly base metal $ Crown - full cast noble metal $ Crown - titanium $ Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $ Re-cement or re-bond indirectly fabricated or prefabricated post and core $ Re-cement or re-bond crown $ Reattachment of tooth fragment, incisal edge or cusp (anterior) $ Prefabricated porcelain/ceramic crown - primary tooth - anterior... $ Prefabricated stainless steel crown - primary tooth $ Prefabricated stainless steel crown - permanent tooth... $ Prefabricated resin crown - anterior primary tooth $ Prefabricated stainless steel crown with resin window - anterior primary tooth $ Protective restoration $ Interim therapeutic restoration - primary dentition $ Restorative foundation for an indirect restoration... $ Core buildup, including any pins when required $ Pin retention - per tooth, in addition to restoration $ Post and core in addition to crown, indirectly fabricated - includes canal preparation $ Each additional indirectly fabricated post - same tooth - includes canal preparation... $ Prefabricated post and core in addition to crown - base metal post; includes canal preparation... $ Each additional prefabricated post - same tooth - base metal post; includes canal preparation... $ Additional procedures to construct new crown under existing partial denture framework... $ Crown repair necessitated by restorative material failure $ Inlay repair necessitated by restorative material failure... $ Onlay repair necessitated by restorative material failure $ Veneer repair necessitated by restorative material failure $ Resin infiltration of incipient smooth surface lesions -limited to permanent molars through age 15 $ IV. ENDODONTICS Pulp cap - direct (excluding final restoration) $ Pulp cap - indirect (excluding final restoration) $ Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $ Pulpal debridement, primary and permanent teeth $ Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development... $ Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $ Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $ Root canal- endodontic therapy, anterior tooth (excluding final restoration) $ Root canal- endodontic therapy, bicuspid tooth (excluding final restoration) $ Root canal- endodontic therapy, molar (excluding final restoration) $ Treatment of root canal obstruction; non-surgical access... $ Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $ Internal root repair of perforation defects $ Retreatment of previous root canal therapy - anterior $ Retreatment of previous root canal therapy - bicuspid $ Retreatment of previous root canal therapy - molar $ Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $ Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $55.00

7 03353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) $ Apicoectomy - anterior $ Apicoectomy - bicuspid (first root) $ Apicoectomy - molar (first root) $ Apicoectomy (each additional root) $ Periradicular surgery without apicoectomy $ Retrograde filling - per root $ Root amputation - per root $ Hemisection (including any root removal), not including root canal therapy $75.00 D4000-D4999 V. PERIODONTICS - Includes preoperative and postoperative evaluations and treatment under a local anesthetic Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $ Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant... $ Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth... $ Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant $ Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant $ Apically positioned flap $ Clinical crown lengthening - hard tissue $ Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $ Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant $ Bone replacement graft - first site in quadrant $ Bone replacement graft - each additional site in quadrant $ Pedicle soft tissue graft procedure $ Oistal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $ Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft $ Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site $ Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months... $ Periodontal scaling and root planing - one to three teeth per quadrant -limited to 4 quadrants during any 12 consecutive months... $ Full mouth debridement to enable comprehensive evaluation and diagnosis -limited to 1 treatment in any 12 consecutive months... $ Periodontal maintenance - limited to 1 treatment each 6 month period... $ Additional periodontal maintenance (within the 6 month period) $ Gingival irrigation - per quadrant No Cost D5000-D5899 VI. PROSTHODONTICS (removable) - For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, ifneeded, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist's facility where the denture was originally delivered. - Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months. - Replacement ofa denture or a partial denture requires the existing denture to be 5+ years old Complete denture - maxillary $ Complete denture - mandibular $ Immediate denture - maxillary $ Immediate denture - mandibular $ Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $ Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $ Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $395.00

8 05214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $ Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $ Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $ Immediate maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $ Immediate mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $ Maxillary partial denture - flexible base (including any clasps, rests and teeth) $ Mandibular partial denture - flexible base (including any clasps, rests and teeth) $ Adjust complete denture - maxillary $ Adjust complete denture - mandibular $ Adjust partial denture - maxillary... $ Adjust partial denture - mandibular... $ Repair broken complete denture base $ Replace missing or broken teeth - complete denture (each tooth) $ Repair resin denture base $ Repair cast framework $ Repair or replace broken clasp - per tooth $ Replace broken teeth - per tooth $ Add tooth to existing partial denture $ Add clasp to existing partial denture - per tooth $ Replace all teeth and acrylic on cast metal framework (maxillary) $ Replace all teeth and acrylic on cast metal framework (mandibular) $ Rebase complete maxillary denture $ Rebase complete mandibular denture $ Rebase maxillary partial denture $ Rebase mandibular partial denture $ Reline complete maxillary denture (chairside) $ Reline complete mandibular denture (chairside) $ Reline maxillary partial denture (chairside) $ Reline mandibular partial denture (chairside) $ Reline complete maxillary denture (laboratory) $ Reline complete mandibular denture (laboratory) $ Reline maxillary partial denture (laboratory) $ Reline mandibular partial denture (laboratory) $ Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months $ Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months $ Tissue conditioning, maxillary $ Tissue conditioning, mandibular $ VII. MAXILLOFACIAL PROSTHETICS - Not Covered VIII. IMPLANT SERVICES - Not Covered IX. PROSTHOOONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge)) - When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $ per unit, beyond the 6th unit. - Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old Pontic - cast high noble metal $ Pontic - cast predominantly base metal $ Pontic - cast noble metal $ Pontic - porcelain fused to high noble metal $ Pontic - porcelain fused to predominantly base metal $ Pontic - porcelain fused to noble metal $ Pontic - porcelain/ceramic $ Pontic - resin with high noble metal $ Pontic - resin with predominantly base metal $235.00

9 06252 Pontic - resin with noble metal $ Retainer inlay - porcelain/ceramic, two surfaces $ Retainer inlay - porcelain/ceramic, three or more surfaces $ Retainer inlay - cast high noble metal, two surfaces $ Retainer inlay - cast high noble metal, three or more surfaces $ Retainer inlay - cast predominantly base metal, two surfaces $ Retainer inlay - cast predominantly base metal, three or more surfaces $ Retainer inlay - cast noble metal, two surfaces $ Retainer inlay - cast noble metal, three or more surfaces $ Retainer onlay - porcelain/ceramic, two surfaces $ Retainer onlay - porcelain/ceramic, three or more surfaces $ Retainer onlay - cast high noble metal, two surfaces $ Retainer onlay - cast high noble metal, three or more surfaces $ Retainer onlay - cast predominantly base metal, two surfaces $ Retainer onlay - cast predominantly base metal, three or more surfaces $ Retainer onlay - cast noble metal, two surfaces $ Retainer onlay - cast noble metal, three or more surfaces $ Retainer crown - resin with high noble metal $ Retainer crown - resin with predominantly base metal $ Retainer crown - resin with noble metal $ Retainer crown - porcelain/ceramic $ Retainer crown - porcelain fused to high noble metal $ Retainer crown - porcelain fused to predominantly base metal $ Retainer crown - porcelain fused to noble metal $ Retainer crown - % cast high noble metal $ Retainer crown - % cast predominantly base metal $ Retainer crown - % cast noble metal $ Retainer crown - % porcelain/ceramic $ Retainer crown - full cast high noble metal $ Retainer crown - full cast predominantly base metal $ Retainer crown - full cast noble metal $ Re-cement or re-bond fixed partial denture $ Stress breaker... $ Fixed partial denture repair necessitated by restorative material failure $ X. ORAL AND MAXILLOFACIAL SURGERY - Includes preoperative and postoperative evaluations and treatment under a local anesthetic Extraction, coronal remnants - deciduous tooth $ Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $ Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated $ Removal of impacted tooth - soft tissue $ Removal of impacted tooth - partially bony $ Removal of impacted tooth - completely bony $ Removal of impacted tooth - completely bony, with unusual surgical complications $ Surgical removal of residual tooth roots (cutting procedure) $ Coronectomy - intentional partial tooth removal $ Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $ Surgical access of an unerupted tooth $ Mobilization of erupted or malpositioned tooth to aid eruption $ Placement of device to facilitate eruption of impacted tooth No Cost Incisional biopsy of oral tissue - soft - does not include pathology laboratory procedures... $ Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $ Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $ Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $ Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $ Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm No Cost

10 07451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm No Cost Removal of lateral exostosis (maxilla or mandible) $ Removal of torus palatinus $ Removal of torus mandibularis $ Incision and drainage of abscess - intraoral soft tissue $ Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure $ Excision of hyperplastic tissue - per arch $ Excision of pericoronal gingiva $ XI. ORTHOOONTICS - The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply. - The Retention Copayment includes adjustments and/or office visits up to 24 months. Pre and post orthodontic records include: The benefit for pre-treatment records and diagnostic services includes: $ Intraoral - complete series of radiographic images Tomographic survey Panoramic radiographic image cephalometric radiographic image - acquisition, measurement and analysis oral/facial photographic images obtained intraorally or extraorally photographic image Oiagnostic casts The benefit for post-treatment records includes: $ Intraoral - complete series of radiographic images Oiagnostic casts Limited orthodontic treatment of the primary dentition $1, Limited orthodontic treatment of the transitional dentition - child or adolescent to age 19 $1, Limited orthodontic treatment of the adolescent dentition - adolescent to age 19 $1, Limited orthodontic treatment of the adult dentition - adults, including covered dependent adult children $1, Interceptive orthodontic treatment of the primary dentition.$1, Interceptive orthodontic treatment of the transitional dentition $1, Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19 $1, Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19.$1, Comprehensive orthodontic treatment of the adult dentition - adults, including covered dependent adult children..$2, Pre-orthodontic treatment examination to monitor growth and development... $ Orthodontic retention (removal of appliances, construction and placement of removable retainers) $ Removable orthodontic retainer adjustment No Cost Unspecified orthodontic procedure, by report - includes treatment planning session $ XII. AOJUNCTIVE GENERAL SERVICES Palliative (emergency) treatment of dental pain - minor procedure $ Regional block anesthesia No Cost Trigeminal division block anesthesia No Cost Local anesthesia in conjunction with operative or surgical procedures No Cost Evaluation for deep sedation or general anesthesia No Cost Oeep sedation/general anesthesia - each 15 minute increment... $ Intravenous moderate (conscious) sedation/analgesia - each 15 minute increment... $ Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician... $ Office visit for observation (during regularly scheduled hours) - no other services performed... $ Office visit - after regularly scheduled hours $ Case presentation, detailed and extensive treatment planning No Cost Cleaning and inspection of removable complete denture, maxillary No Cost Cleaning and inspection of removable complete denture, mandibular No Cost Cleaning and inspection of removable partial denture, maxillary No Cost Cleaning and inspection of removable partial denture, mandibular No Cost Occlusal guard, by report - limited to 1 in 3 years $ Occlusal guard adjustment... $10.00

11 09951 Occlusal adjustment, limited $ Occlusal adjustment, complete $ External bleaching for home application, per arch; includes materials and fabrication of custom trays - limited to one bleaching tray and gel for two weeks of self-treatment $ Missed appointment - without 24 hour notice - per 15 minutes of appointment time - up to an overall maximum of $40.00 $ Canceled appointment - without 24 hour notice - per 15 minutes of appointment time - up to an overall maximum of $40.00 $10.00 If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized by Delta Dental. The Enrollee pays the Copayment specified for such services. Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed fees." "Filed fees" means the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department at

12 Limitations and Exclusions of Benefits SCHEDULE B Limitations of Benefits 1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and Copayments. 2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $ above the listed Copayment for each of these services after the sixth unit has been provided. 3. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241). 4. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis. 5. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on the Contract Orthodontist's usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged. 6. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA Program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases. Exclusions of Benefits 1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments. 2. Any procedure that in the professional opinion of the Contract Dentist: a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or b. is inconsistent with generally accepted standards for dentistry. 3. Services solely for cosmetic purposes, with the exception of procedure D9975 (External bleaching for home application, per arch), or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth abnormalities. 4. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age. 5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges). 6. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ). 7. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures. 8. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant. 9. Consultations for non-covered benefits. 10. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a Contract Orthodontist except for Emergency Services as described in the Contract and/or Evidence of Coverage. 11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility. 12. Prescription drugs.

13 Limitations and Exclusions of Benefits 13. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee's eligibility with the DeltaCare USA Program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics unless qualified for the orthodontic treatment in progress provision. 14. Lost, stolen or broken orthodontic appliances. 15. Changes in orthodontic treatment necessitated by accident of any kind. 16. Myofunctional and parafunctional appliances and/or therapies, with the exception of procedure D9940 (occlusal guard, per report). 17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. 18. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.

14 Wellness Program Find all of our dental health resources, including a risk assessment tool, articles, videos and a free e-newsletter subscription, at: mysmileway.com. DeltaCare USA Customer Service NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage will be sent to you upon enrollment. Ifyou wish to review an Evidence of Coverage prior to enrollment, you may request a copy by calling Customer Service at In California, DeltaCare USA is underwritten by Delta Dental ofcalifornia and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products. Customer Service Monday through Friday 5 a.m. to 6 p.m., Pacific time Provided by: Delta Dental of California Park Plaza Drive, Suite 200 Cerritos, CA Administered by: Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA o DELTA DENTAL" deltadentalins.com/enrollees AREGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION

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